The Baby and the Bath Water: Responding to and Interpreting Learner Feedback

Hey welcome everybody it's so so good to see you all and to feel you all if only virtually I know it could be quite isolating in these circumstances but I am so glad to have you all here I trust and hope you all are safe and healthy physically mentally emotionally if you have any needs in these areas please Karelian and Virginia Tech Karelian School of Medicine have multiple resources for you all to reach out to if for some reason you've missed any of those don't hesitate to contact us and we're more than help happy to help link you up with those resources what we're going to do I think for this session is to for the most part we're going to stay muted and minimize the use disabled the use of your video function so that we can minimize the strain on the bandwidth which is where we get a lot of the static and the brikene up if you do have a question at the very bottom of your screen if you float over there's a little chat function you can click on chat and you will see the chat pop up on the right side of your screen you should and then you can add some questions through there or there will be a point at which dr. Foley will open up and ask if anybody has questions and then you can feel free at that point to unmute yourselves and you can share your video if you so desire at that point but if nobody have any questions before we get started I'm going to go ahead and introduce today's speaker and happen so today's session is feedback - so responding to and interpreting learner feedback it's the second session and it's - two sessions set it's not a dr. paul is going to cover a lot of what was in the first session or just in a quick review if you want to go back and watch the first session retrospectively can still do that because they're recorded and on the cheat website but it's not necessary that you participated in that session so our speaker today is dr. Rebecca poly she's a professor in internal medicine she's one of our outstanding educators and she's agreed to do this session on the previous session and any additional sessions related to feedback in a variety of other topics and she's also available if you the additional concern subsequent to these sessions she is happy to talk with you and guide you in a customized approach or consult with you so right now I'm going to mute myself and I'm gonna stop sharing my video I'll be back at the end but I want to turn it right over to dr. quality please join me in welcoming dr. Rebecca poly thank you very much sherry and I too want to extend a welcome and thank you for joining us so we're going to get started and the title is the baby and the bathwater whispering responding to learners feedback so our learning objectives are to interpret trends and outliers in feedback data tease out our teaching style from curriculum content in feedback that we received recognize the value of peer teaching assessments to enhance the data that we receive from learners comments and to develop a focus strategy in responding to identify gaps in our style or curriculum and then to test the new implementation strategies so these are in a current and challenging times in their changing times so I selected this slide of dr. Burks who those of us who watch the White House Task Force updates have to come familiar with dr. Burks and just to point out the very unusual times in which we exist just to emphasize that we've become familiar with her leadership characteristics and her her strengths but also we know her scarves and in fact her scarves have received recognition and there's actually an Instagram account deborah birx scarves and on last check these had over 33,000 followers just a point what unusual times these are and how unsettling these times can be and so in thinking about that I selected an anchor for us to focus on and the anchor reflects that there are images that we can go to to think about places that that we can have strength and focus and then I ask the question are there anchoring principles related to feedback things that we can think of it steadying and grounding us and the answer to that is yes there are anchoring principles and those are the principles of being driven by data the fact that we want to gather that data from multiple and direct sources it should be collected and provided and analyzed in a timely fashion and if you think about what happens when it's not collected provided or analyzed in a timely fashion then it becomes very diffuse and it's less reliable it needs to be provided and interpreted without emotions and then it needs to be allowed to be reflected upon and then responded so that improvements can be made so these are anchoring principles that relate to one we both provide and receive feedback so I want to spend just a little bit of time reviewing what we touched on in session one as a reflection but also for those who weren't able to participate with us in that session so in thinking about feedback remember that its formative so it's meant to allow us to adapt and to improve we're evaluation is summative and it's judgmental so feedback should follow clear expectations or learning objectives which are laid out that at the beginning of a rotation or any sort of teaching opportunity and if learners do not receive clear expectations then they're blindsided by the feedback and they really don't know what what they're being evaluated or what they're receiving this input related to it's used to appreciate the good and right things with a logical explanation of why that is good or why that is the correct way to do a certain procedure or technique it helps to identify the bad and wrong things and it provides a logical approach to why the bad or wrong thing should be changed now it's important to name something as feedbag oftentimes we might think we're providing feedback but it goes past the learner it's not captured in their mind as actual feedback so you can use a statement as simple as I'm now going to provide you feedback and that should be quickly followed by as you recall I'm providing a feedback related to what we laid out at the beginning of our as our learning expectations and then followed by let me understand your perception of how you've done so you're trying to determine the learners inside related to his or her perform now you want to be specific because words really do matter you want to avoid terms such as good job it was nice to have you along the team that's just not specific enough you want to be descriptive and if you can relate something that you observed that was very definitive related to performance of that particular owner that's the most helpful because that will reinforce that specific behavior so what happens if little or no feedback is given well good performance is not reinforced and poor performance remains uncorrect 'add well what the learner may assume all as well they may have to rely on hearsay from peers to get the feedback that they so desperately need they may have to guess their level of competence based on how they're coping they may have to learn by trial and error at a patience our colleagues expense and this could become a patient safety issue so we're going to talk just a minute about the pendant Pendelton model which replaces the traditional traditional feedback sandwich which I think most everyone is familiar with so the traditional sandwich was a three layer sandwich with the bread and then the meat of the sandwich and then the bread so this was you would tell the learner something that was good which represented the bread and then the meat of the sandwich was where hit them with what you really wanted to say which was where they could talk or move and then you close with what was good well this has been found not to be that effective so it was replaced with what is the Pendleton model which is a 4 layer sandwich in a sense so you would ask the learner will tell me something that you think you did particularly well on this rotation and then you would come with your comment reinforcing what was good and then you would ask the learner to list something that was an area that needed improvement in the learners mind and then you would then tackle that area and say well yes I agree with you that is something that I didn't think you did particularly well and let's work together to think how we could make that better so this as you can see it's much more of a dialogue and it really focuses on action to improve so let's focus now a little bit on the new concept so a fundamental concept in responding to learners feedback is very similar to what we were talking about in providing the feedback and that is expectations so let's begin at the end in a sense and look at it the evaluation form for us as teachers so what are the expectations that the learners have of us as teachers in other words on what is our teaching being evaluated so when we look at the clerkship evaluation categories the expectations and these are on a scale of one to four with one being unacceptable and then for being exceeds with ranging from unacceptable to below expectations to meets to exceeds and the categories are supportive environment provided feedback our availability our function as a role model for patient care student participation cultural sensitivity professionalism and respect and overall effectiveness so now that we know the expectations now what so what might we do differently since we know these categories so one idea might be at the beginning of your two-week rotation as Sesa agenda for the team saying something such as it's important that we create a supportive environment where everyone on the team has an opportunity to express himself or herself if you ever feel that this is not the case please speak up and let me know I will have office hours on Wednesday afternoon at 4:30 to allow for check-in and be sure that we have scheduled feedback time so this really addresses a few of the categories it gets that supportive environment it addresses providing an opportunity for schedule feedback it also addresses availability so you knowing that these are areas that you're going to be critiqued on you've addressed those upfront at the beginning of the rotation so now let's look at the lecture evaluation categories the expectations and these range from one to five with that being strongly disagree to disagree to a neutral I'm just to agree to strongly agree so these categories contain both content and style so effectively organize content flow and pace of the session effectively answer questions to ensure understanding of material took time to explain difficult concepts content was important for learning styles of this faculty members sessions were effective learning modalities this faculty members sessions increase my understanding of the topics covered I would rate this faculty member as an effective teacher so knowing these expectations now what so you might begin your lecture with the following comments we have a lot of material to cover in this lecture and I want to be sure we go and an pace not too slow and not too fast I will check in with you from time to time and ask that specific question I also will pause at certain points to see if you have questions it is better to let me explain the concept in details without interruption and then ask for questions we will include a patient presentation which hopefully will tie in the concept and show you how relevant and valuable our topics are for your clinical experiences so this I think addressed some of the categories mentioned in the evaluation so also important are the narrative questions so what did you find effective about this faculty members sessions what can be done to improve this faculty members sessions and what did you exceed your experience any unprofessional behavior from this presenter so I'm going to pause now for dialogue and see if we have any comments from the chat line or by phone I don't have anything on the chat line yet dr. Polly okay feel free to unmute your line if you'd like to ask a question at this time dr. Polly we'll wait just a minute you can also enable your video so that you pop up or not feel nothing okay if they're okay you just don't hesitate to type them right in that chat box and then we're going on from there we did get something pretty that says you're doing a great job so okay so we'll we'll keep going and we'll have time at the end for questions as well so I'll be curious to see if how many folks have thought about looking at the evaluations form to creating lectures or approaching clinical rotations and just that concept of sort of looking at the end priority of beginning but we can talk about that as we move on so I'm going to talk a little bit about an article that was in the December 2019 edition of academic medicine that I think it's applicable to teaching feedback this really relates to clinical feedback but I'm going to summarize it here but as I said I do think it's related and can be applied so academic medicine 2019 is reflections from the rearview mirror internal medicine physicians reactions to clinical feedback after transitions of responsibility and these are some what I would describe as inner internationally recognized medical educators or heavy hitters in it's a study from Oregon Health Sciences University yeah it's a subset of a larger study but it's 22 internal medicine physicians 12 or hospitalist 10 were internal medicine residents who completed semi-structured interviews following a transition of care and what they asked them to do was to select two cases that they were involved in that they made the initial diagnosis and then transferred care to another internal medicine provider and one of the cases was to be where they correctly made the diagnosis so the initial provisional diagnosis was the same as the final diagnosis and then another case where the diagnosis was different from the final diagnosis and then the interview questions related to how the providers felt about that and then what sort of changes in practice they might do based on the feedback they received that the diagnosis went back they realized the diagnosis had changed so they were terming this confirmed diagnosis or dis confirming the final diagnosis so the study looked at how clinical feedback could be used to refine diagnostic approach in how responding to feedback could shape future clinical performance so for us I thought it was interesting to reflect on this concept and whether it might be translatable to teaching practice in feedback and teaching and this was termed as learning about practice through practice and then I sort of termed it learning about teaching through practice so what did they learn and what can we learn so interestingly when the diagnosis was confirmed the emotional response was positive and 15 out of 15 cases they described their emotional response in words such as it was exciting satisfying interesting fun they felt proud and confident I will say that initially there were 51 cases age were eliminated or excluded because there was no real transition and care and 9 were excluded because of there was no final diagnosis that could be proven so that's why there's this mismatch of fifteen verses 34 in the confirming verses disconfirming number of cases so when the disconfirming cases the emotional response that the physicians felt was either neutral or negative in 31 of the 34 cases and the emotions that they described were frustrated feeling terrible upset they doubted their ability they were disappointed they felt weak I thought what was particularly interesting is they then employed behaviors such as rationalization in use terms as well nothing really bad happen to the patient and there were four or five other consultants on the case and they also didn't get the correct diagnosis so they started bringing in behaviors such as rationalization to balance these really negative emotions they were asked well what would you do differently and in reflection some of the responses were well I would slow down you know I just looked at the echo how others interpreted the echocardiogram and their notes I didn't go back to the primary report I guess I should do that next time I'm going to be more cautious I need to obtain more knowledge they reflected on performance gaps and there was evidence that the experience of the physician the physician self-confidence and willingness to learn play critical roles in their openness to respond to next steps so I thought this was really interesting and it pointed important roles of emotions in our response to feedback and our willingness to change so I have I wrote a couple of cases for us to reflect on and to think about emotions and how we might respond to feedback and that the whole concept of not wanting to throw out the baby with the bathwater as we're getting these our evaluations and feedback so in looking at the first case dr. Thomas has gathered his teaching evaluations for the past five years in preparation for promotion he has 25 student comments with 21 being mostly in the exceeds and meets expectation range however four of the evaluations are below expectations in availability and student participation upset and can only focus on the four low evaluation he thinks what more could I have done I've bent over backwards to be there and even ran over to give extra teaching sessions on days when I had planned to have a little me time I distinctly remember missing my daughter's softball game to show the students physical exam findings how could I be in low availability and student participation I bet nobody else gets high in these categories I think the other categories are more important you know I was thinking of focusing on teaching and the residents and fellows for next year but wait how is this going to look in my promotion packet so dr. Thomas is clearly emotionally engaged in his response and he's using rationalization so I think he could benefit from peer and/or observational input in his teaching style from the teach program he could think about establishing some agenda as related to availability and student involvement with his learning objectives when he begins the clerkship for his next round as we talked a little bit about and he could implement new strategies and measure their effect what ideas I'm going to open up to see what you guys think so remember he was in availability and student participation was where he was below expectations do you have some ideas of specific things that he might do to improve I have some responses on chat and have asked what his peers are doing in this mmm excuse me ask what his peers are doing in those domains okay that's good so he could ask what his peers are doing he might even request to maybe round with up here and see firsthand what someone else is doing okay I have another comment I was once a student and am pretty sure that my judgment was not so sound when I gave feedback another comment is could be students perceptions right it's been and I think that's why it's so important to have peer input as well because you know if you just have a single input and that's the learner input then you know that that can be just it's you know dimensional so it can be influenced by many things personality you know it's it's one perspective so having peer additional faculty input broadens of perspective have another comment that says ask the students that the meeting comes provided are sufficient for them each student good good and I think check-in time so you know if you're in each context is different so if you're just rotating with the student you know the student is rotating with you for a very short time you know some some of the rotations or as short as you know a single session and clinic so you know that's very abbreviated so it's not going to fit for some of these ideas but if you're working with the student you know in a more continuous continuity kind of experience then it's going to allow you to adapt and make changes and see how those play out or if you're on a if a student's on with you for a month then you can make changes in week one and see how that plays out over the you know subsequent weeks so you know certain kinds of rotations are going to be more amenable to the alterations in the schedule and working with them okay any more thought I'd given up several more comments I'm just going through them said could he review feedback on yearly rather than five year basis perhaps there was a year where he could explain his availability or lack thereof I like being able to address things one of the you know our evaluation system has some pluses and minuses sometimes in some venues you the the evaluations are batched so that the faculty member doesn't necessarily get the faculty member doesn't necessarily get the information right away so they don't have a chance to address the concern right away so it may be a month or two down the line before they're able to get the information so I think as close proximity to when it happened is good certainly you know to to read and review your evaluations as soon as possible is is helpful I think and we always have to I know there's that element well maybe maybe it's just the students perception but I think we always have to consider that perception is at least their reality and it's we just have to see is this a single one-off thing or are there multiple instances of the same thing that's just right and right and the fact that there were four you know does at least raise some concern you know that that it wasn't just one student mean oh yeah we also have tailed any new students straight up what you have had difficulty with in the past and how we can make this vacation inclusive and an access to the teacher available the next comment is provide different types of that the availability being reachable by phone text or video chat to field questions or concerns that's the end of the comments so far okay great well I did I do think that I think those last two are very helpful too and just you know put that out there at the very beginning that you know I want to be available to you and this is important to me and these are the ways you can reach me and then you know say to the the learners the residents the students why don't you guys go ahead and text me and then that way I've got your number and you've got my number and I find that's very helpful good okay so hopefully those thoughts and comments as well as encouraging dr. Thomas to work with teach and having them observe and give him some more feedback will help so now we're going to move on to example number two and dr. Frederick received her evaluations for her online session this semester and she says in an discouraged once unit said thanks for an effort in this trying time we know this was a first for you the coming tenant was obviously important for us to learn we wish we'd had better connection for our session another student said the material was just so din can you make it more interactive please not and please try not to talk at us so now what dr. Frederick had been worried that all the graphs and figures were too dense but she was not sure how to better communicate the facts normally she brings some patients in the class which had relevance to the material she'd hoped to find patient videos but no luck she had wanted to use them and had the students lead some of the discussion but the video connection on the day of her session was not working well she heard from other professors that they had better connection on their days should she have tried to reschedule ideas from anyone who has been working with virtual classrooms any thoughts that might have helped that to project don't have any comments right now so I think you know in this transition time folks have been looking for best practices looking to see what other universities have put out been willing to share and you know it really is a lot of uncharted waters and we're trying to to learn from each other does anyone want to share any resources that you've found work particularly helpful related to those I've got to come in to check in with students a on various parts of the lecture to ensure that they can still hear her see the graphs or need to revisit any info that may have been unclear the total right and also to share the presentation so that it's available offline as well I like I also think that we have some resources on teach that will allow you it shows you super-easy how to create a voiceover PowerPoint so let's say somebody missed dr. Pauly's presentation today she could recreate it if we weren't videotaping it she recreated in a just a simple voice over PowerPoint and post it online or send it out to her students but also checking in periodically just as dr. paulie's doing to make sure everybody's still on the same page and and understanding in the way that they should so they all have the common understanding okay great so as I mentioned the peer feedback opportunities the teach program offers this and it's so important because it provides direct observation it's applicable to many venues so this ranges from watching online so coming to your office and watching a virtual classroom presentation making some tips pointers of how to stay connected through tips such as sherry was sharing just now going to a rounding clinical new small group activities a traditional lecture format teaching in a procedural aspect there are so many teaching venues that one can be observed in and this is truly formative with the specifics of narrative comments being given and it's confidential one-on-one with the faculty member and it's also encouraged that follow up with repeat observation focused on the areas that are identified for the faculty member to improve and also importantly it's asked of the faculty member which area would you like for the the teach faculty to really focus on and it can be included in the promotion packet but that's up to the faculty members discretion so I just took from the teach observation documents a couple of the areas that can be focused on so content and that relates just highlighting a few areas learning objectives overall knowledge and content learner centered miss do they hold the learners attention did they demonstrate respect interpersonal and communications problem solved in a social context professionalism and role modeling are they well-prepared are they timely are they inspiring practice based reflection and improvement do they seek faculty development opportunities to improve educational practice are they incorporating some of these newer techniques into their education modalities and system basically earning utilizing medical education and resources to advocate for learners so I'm kind of wrapping up now I'm going to leave a little time for opportunities for general discussion but hopefully what we've pointed out is that responding to feedback is a dynamic process it is data driven it follows expectations our response should include limiting our emotions it should incorporate peer input and then we should develop strategies for our goals of an improvement and those should really go back to thinking about the expectations on which we can build and then it's not that we're really directing ourselves to focus solely on sort of the the grade so to speak or teach to the test but knowing what we're being evaluated on or what the expectations are help us build our teaching opportunity so that that we're all on the same page so to speak so I'm opening this up for general questions and I'd like for you as you're asking the questions too to think about one of your times when you received feedback or evaluations that you felt blindsided and why why did you feel that and thinking about these expectations and in reflecting on that do you think now that that might have decreased that sense of being blindsided feel free to either type in the chat or don't hesitate at this point to open your mics and/or video oh with any questions or statements you'd like to make and did did it surprise you at all that the response to the clinical feedback was emotionally charged particularly with the contrast of the positive and more negative emotions depending on whether the diagnosis was confirmed or not confirmed and and do you find that you tend to focus on those two or three evaluations that are not in the exceeds categories when when you get your evaluations back I think that's one of my concerns always is no matter what when I could be presenting to a hundred individuals and I could receive one or two slightly not ideal comments even if they're constructive and then I fixate on them and I try I think the best thing to do for me at that point is to put them aside for a minute take a breath get back get somebody usually that I feel very comfortable with that that's a colleague just talk it out to figure out okay did you notice this or have you ever had an experience you know getting comments like these and really the more you just sort of sit through them and process and reflect I think those comments because perception is reality it's not that you know they perceived it to be that way it was true you can say all you want well I was super accessible but if they felt that you weren't accessible then you need to reflect and and identify why they may have felt that way so that's what I tried to do just separate from it a little bit and then come back and revisit it and see how I can do it differently the next time yeah we have several comments let's start with this one I think we should make it clear there are so many atypical presentations of a these process like mi ko bid long as the diagnostic algorithm is followed and a reasonable differential is reached it is alright the next comment is I think whether the diagnosis is confirmed or not excuse me it's confirmed or not confirmed is an emotional element is a feature I'm sorry hold on is a feature as important as an important observation we are taught to try to get the right answer not to learn how to develop a method of searching the last comment is I would be worried if the doctor did not have an emotional response about the diagnosis being confirmed or not confirmed I think that's not a part of a part of the conversation right we always encourage this conversation a part of the conversation is learning to deal with in medicine ambiguity when that's one of the most difficult things to be able to learn and not just finding out what is the right answer but knowing that you're not always going to know the right answer and how to approach that in the best and I in the best way and actually role modeling as a faculty member how to do those types of things what are your thoughts on that Polly well I think I think those are really interesting points to come away with and you know I do absolutely agree that it's you you know we really it's very important to throw a wide net and create a broad differential and it's it's interesting it's not like we're taking a test to get a right answer I mean we want to get the correct diagnosis because we're taking care of a person and we want to do the best care for a person but we also we're human and we want to learn from our mistakes and we want to grow and and we do care and so and we want to do a good job so it does make sense that we would be disappointed in ourselves if we miss something but I think the response is how do we do better and so I guess yeah if you're kind of a mall it's a big mix isn't it and we're we're lifelong learners and how do we then become better rather than become bitter and I felt some of the emotions that were described and the rationalization may be tended a little bit toward bitterness so I you know is in this and where we are right now you know going back to sort of the early part of current times you know what can we do to avoid burnout and bitterness and isolation you know to take care of each other as it's so important I think and also trying to be comfortable with without being perfect and just letting sharing with your learner's that you're not perfect and they should not push themselves to be or else that's going to lead to burnout there are there are ways to help you're not always gonna know all the answers but show them how to find the answers I think it's important that see okay we have another comment I find it easier to get feedback on learner medical knowledge or patient care but it is more difficult to provide feedback on professionalism for instance when we have a learner who makes micro professionalism errors and that add up over time multiple faculty may pick up on this and chop it up - oh he's tired or whatever but when faculty meet and discuss this is a that needs to be addressed any tips on how to provide a woman or with feedback on this in a sensitive respectful but direct Amina well I think trying to determine insight on the part of the learner is the place to start and to if the learner has any glimmer of insight and that allows you to just to open up discussion related to professionalism and then if you if you have things that you've observed directly and they you can then say well in this particular situation do you think that showed professionalism and you can begin to have a dialogue if they show some insight if they don't show inside and you have some specific examples you can you can still bring those up and say to the learner you know there were things about that particular example or encounter that I would have to describe as less than professional and this is what I think you could have done to be more professional so I think you just have to spell it out as concrete and say to them what you would have done that would be more professional in your mind and then loop back and say you know I'd like I'd like to give you another chance I'd like to see you play this out again in a different situation so you're not closing the door on them and saying you know I'm putting you in enough professional category I'm going to give you a chance and let me do demonstrate again I think that's an excellent point and like you talked about in your part one of this two-part session is establishing their their level of insight so at the beginning of a conversation whenever I'm getting feedback are we try to say you know when I do an observation so how do you think that went I mean that's a really general statement but you can make that even more specific so do you think that you were as professional at all points in there in that situation as you could have been or what are some ways that you could have been even more professional or what what would you have done differently some things like that somebody commented can you give us an example of an error of micro professionalism and that was a question that came from somebody else so I will try to address that unless you would like to dr. Polly all right you go ahead sherry so I was the one that comes to mind I was thinking that micro professionalism are just small errors professionalism errors that may build up along the way so maybe if you're if you're in a group setting and I don't know you're referring to you're referring to your attending by their first name which would may be fine to do in another situation but in front of the patient that probably wouldn't be the best just little lapses and professionalism and then you notice that another attending notice another small lapse of professionalism that add up to maybe a macro I'm not sure if I'm understanding that correctly but if you have another example that would be great I would think oh I was thinking about saying being late to rounds you know and maybe with an excuse you know the car wouldn't start or you know something and and then you know another day you could tell the person oh well you know I didn't see that person on rounds because you know they were they were off in a study or they were and they kind of added up and you started thinking well gosh there's several days in a row that there were a few patients you didn't see I'm starting to wonder you know are you really coming in giving yourself enough time to do these rounds or is the patient really not that accessible day after day don't kind of anything else any other questions or comments also please remember that if you are interested in CME credit or credit your faculty development really agents teaching credit look in your zoom appointment on your calendar the notes section and it will give you instructions on exactly how to do that this was a wonderful session thank you so much dr. Foley you did an excellent job of really providing a case based discussion with practical suggestions for next steps which is difficult to do any unique environment I was thrilled to have so many of you join us we had close to a hundred I think 98 at our highest point for the majority of the time I think that meeting like this that's all to feel some sort of sense of normalcy and allowing me faculty development related to teaching at the same time in these completely abnormal times and as dr. Paula mentioned I want to make sure to remind you all that if you go to our teach website we have plenty of resources we have a whole new page that will give you one click resources for teaching online we did we curate curated these very carefully so that it wasn't just a list that would lead you down a bunch of rabbit holes these are one-click resources you click on them and you can get right to where you need to go there are super short videos we named them hat for intentionally because all of them I think with the exception of one or under four minutes in length that will help guide you on to how best bring your teaching online we are also always offering consultations and observations so even in this environment I just observed some somebody last Monday in there providing an online lecture to their medical students and then we do is we do a pre-brief so we just sort of figure out what you want us to be watching out for and then we actually do the observation we'll just zoom in with you and then we have a debrie that will help provide the feedback so if there's anything else that we can do to help you all please let us know we're here for you we know it's a trying time and whatever we can do to help out we're more than happy to do so let us know if there's nothing else I hope you all have a wonderful rest of the day they safe and healthy thank you thank you dr. Polly.